Monday, July 21, 2008

Barriers to use and referral: challenge

As time has passed I have been able to identify some of the potential barriers to use and to referral. I thought I would share these as they may benefit those of you who are interested in implementing a similar health information service at point of care (I know of at least one other centre that is considering doing so). That said I feel I should emphasize that this is based on my own personal observations and on the casually reported observations of others, rather than on any systematic study of the issue. We do intend to do a formal evaluation of the service, at which point we will be able to see whether these hypothesis are correct.

Not in order of importance:

Distractions in the waiting room. We have two big, beautiful, flat screen TVs in the waiting room that are impossible to ignore if you're sitting there, no matter which way you're facing. I just went out there to see what's playing. On one you have a talk show and on the other a soap opera. Even on mute they seem to be serious competition for my service. Gone are the interminable boring waits during which patients had time to think about where they were (the doctor's office), why they were there (sickness, checkup etc.), and maybe formulate a few questions they'd like answered. You may want to think about what could potentially distract your users from dropping in with questions. It could be TVs. It could be something else.

The good a) patient satisfaction no doubt increases (time flies when you're having fun), b) as far as the TVs are concerned, there is an opportunity for promotion, to develop programming that could include information about the clinic and the service. The bad people may be distracted from asking questions while they wait.

The InfoRx. On the part of the HP, there may be uncertainty about how to insert the referral into a transaction with the patient. It may be hard for HPs to know when would be a good time to mention it, or who might benefit. Time is certainly a factor and it is probably all too easy to forget to write up an InfoRx. Telling HPs that they should consider referring a patient whenever they make a new diagnosis, prescribe a new medication, or the patient is faced with a treatment decision may not be enough. The idea that a librarian is now acting as a member of the team at point of care and can have patients referred to them same as any other specialist may be new and it may take a long time before knowledge becomes practice, even when everyone buys in to the idea. My feeling is that this is a change management issue. It has to do with the gap between theory and practice, between intention and action.

Hoping to find something along the lines of the PLISSIT model* that could be used to assist health professionals at that crucial moment during their visit with the patient and family, I've been doing some reading about barriers to improving practice, and barriers to implementing practice guidelines and shared-decision-making. I think the latter is particularly relevant, because helping a patient or family member become well informed is a crucial component of the shared-decision-making process.**

The bad this is a very complex issue that may be difficult, if not impossible, to solve, The good this could be an opportunity to further develop a new model of health care, and there may be evidence to help us in the process.

The Internet. You will likely wish to have a web component to your service, as I have done. Our website is advertised in our H-PHIS brochures whichare disappearing from the displays at a steady rate. Statistics show that the website is being visited regularly. From this I feel I can say that I am successfully helping people help themselves.I wonder if this makes them less likely to ask for help.

The good people will probably use a website if you have one, The bad people may go to your website instead of using your service.

Availability. It is unlikely that you will be on site and available every day all day. I am only on site 7 hrs per week, and the librarian at the Monkfield Medical Practice was also there only part time. This means that you may not always be available when needed, and not always be around to remind people to use the service and to guide people through the process. The point of having a service on site is to avoid the whole "out of site out of mind" thing.

The good the demand may be greater than the supply, which may justify an increase in staffed hours The bad not having enough hours to make the service work.

I would love to know your thoughts on these issues, so any comments or suggestions from my readers are very welcome. Since I began writing this post I have found a couple of models that may be useful in facilitating shared-decision-making. Stay tuned. I will discuss them in my next posts...

*I came across this model recently while researching the question of how to help HPs bring up sexuality issues with gynecologic cancer patients.

**Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bulletin of the World Health Organization 2004;82:724-32.

About Info.Rx

Update:

In the fall of 2008 a Clinical Medical Librarianship component was added to the service. The librarian now acts as a resident supervisor in the teaching rooms at the clinic one half-day per week, providing support for clinical decision-making in addition to continued support for patient education.

The service is based on an innovative InformationRx model first implemented in the UK (see: Early experience of thecontribution of an information specialist within a primaryhealthcare team: a partnership venture betweenlibrary and healthcare services, doi: 10.1177/0961000604048915].

This model sees the information professional acting as a member of the health care team by providing informational/instructional support for patients/families and health professionals at point of care. Support for the service is provided by the main hospital library and is vital for ensuring long term sustainability.

The information professional is available 7 hrs per week to consult with patients/families that are in need of health information.

Health staff are encouraged to write InformationRx for patients which can then be filled by the information professional. Consultations with patients are treated as clinical encounters and are documented in the charts. The service has a clinic in the Centre's appointment scheduling software.

Patients and family members are welcome to drop in, or to submit questions by phone or email at their convenience. They can schedule appointments by contacting the information professional directly or by calling their team coordinator.

The library provides support by welcoming questions from patients and their families when the coordinator is not available. Herzl patients and families are able to borrow books from the Patient and Family Resource Centre's (PFRC) print collection, and a family medicine section has been created on the PFRC website which provides links to reliable and up-to-date consumer health resources.

Author"s note

Important: While based on real consultations, the cases posted in this blog have been mashed up, fictionalized, posted out of sequence, and otherwise tinkered with in order to maintain the privacy and comfort of the parties involved.

Also, the views and opinions expressed in this blog are strictly my own and do not necessarily reflect those of my employers.

About this blog

The Patient health Information Service at Herzl (H-PHIS) opened its doors in early July of this year (2007) and is in the early developmental stages. The challenges faced by myself (the service's coordinator), the staff, and the health care team at the HFPC are many and varied, as is to be expected when implementing a new and innovative service.

Perhaps the most unique aspect of the InfoRx model is the presence and participation of the information professional/librarian at point of care. This new and multidisciplinary approach presents a distinctive challenge. Health and support staff are not always clear on what knowledge and skills a librarian brings to the team. Conversely, I must be able to recognize and adapt to the needs and character of the community and of the setting itself.

This blog was created in response to some very astute and constructive criticism. After presenting to the residents at their weekly rounds, I was approached by one of the partners at the clinic who suggested that rather than introducing myself and the service and then explaining how to use it, it would have been more effective to present some cases illustrating what the service has to offer to the residents and to their patients. I see this as a perfect example of the kind of disconnect that can happen when two very different professions come together. In essence I had presented the way I would have to my own professional colleagues, but this was not the most appropriate approach given my audience.

After giving it some thought it occurred to me that it could be useful, both for myself and the rest of the team, for me to present a weekly case here, and talk about some of the challenges we are faced with and how these might best be resolved. Hopefully this will introduce some transparency to the InfoRx process.

This is meant to serve as a record of, and forum for discussion about, our challenges and successes. It is hopefully also an opportunity for other information professionals to be inspired by one example of what can be accomplished outside of the library setting.

About Me

Francesca Frati has an MLIS from Dalhousie University and is the wearer of many interconnected professional hats. She works at the SMBD Jewish General Hospital Health Sciences Library (HSL) as Patient Information Specialist and Instruction Librarian, at the Herzl Family Practise Centre (HFPC) as Patient Information Coordinator, and in her spare (work) time provides research support for physicians.
Francesca is a member of the advisory committee for the Society of Teachers of Family Medicine (STFM) Conference on Practise Improvement: "Blueprint for the Medical Home".